Fluid & Electrolyte Q 10

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Which of the following is the most important physical assessment parameter the nurse would consider when assessing fluid and electrolyte imbalance?

  

    A. Skin turgor

    B. Intake and output

    C. Osmotic pressure

    D. Cardiac rate and rhythm

    

    

Correct Answer: D. Cardiac rate and rhythm

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Cardiac rate and rhythm are the most important physical assessment parameter to measure. Skin turgor, intake, and output are physical assessment parameters a nurse would consider when assessing fluid and electrolyte imbalance, but choice d is the most important. Tachycardia and hypertension are common manifestations. Tachypnea is usually present with or without dyspnea. Elevated CVP may be noted before dyspnea and adventitious breath sounds occur. Hypertension may be a primary disorder or occur secondary to other associated conditions such as heart failure.

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Option A: Skin turgor is a sign of fluid loss (dehydration). Diarrhea or vomiting can cause fluid loss. Infants and young children with these conditions can rapidly lose a lot of fluid if they do not take enough water. Fever speeds up this process. To check for skin turgor, the health care provider grasps the skin between two fingers so that it is tented up. Commonly on the lower arm or abdomen is checked. The skin is held for a few seconds then released.

Option B: These measurements are important to help evaluate a person’s fluid and electrolyte balance, to suggest various diagnoses and allows for a prompt intervention to correct the imbalance. Records of all intake and output must be kept meticulously in an Intake and Output Chart (I/O Chart).

Option C: Osmosis is the diffusion of water across a membrane in response to osmotic pressure caused by an imbalance of molecules on either side of the membrane. Osmoregulation is the process of maintenance of salt and water balance ( osmotic balance) across membranes within the body’s fluids, which are composed of water, plus electrolytes, and non-electrolytes.

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